2.0 Analysis 2.1 Introduction The aims of the trip were educational and recreational. The completion of this trip was supposed to give the charterers the necessary skills to plan and execute a sea-kayak trip. Because the guides relied on individuals to feel comfortable with their own capabilities and experience, not all the charterers were forced to complete all the training given. Given the level of expertise of the majority of the charterers, the training given to them before setting out was not sufficient to ensure the survival of all the participants when bad weather was encountered. 2.2 Pre-Trip Training for Emergencies Although she had assisted other members of the group in kayak-righting exercises, the woman in the kayak which became separated from group one had not practised righting a kayak during the period of instruction given by the guides. In spite of this, she was able to right the kayak and at least partially get out of the cold water. Because no one saw the man who died of hypothermia and drowning after he became separated from the main group, it is not known how he came to be in the water beside his kayak. Similarly, it could not be determined if he had performed righting exercises during training. 2.3 Interpretation of Weather Forecasts As the head guide had interpreted the weather forecast to mean that winds were diminishing, the trip for the day was continued. Although familiar with the area, the head guide did not fully anticipate the effect of large seas on the group of inexperienced people he was leading. 2.4 Clothing Although the owner of the kayaks was aware of the benefits of wearing a wet suit which provides good protection against hypothermia, charterers were left to decide whether to wear one or not. The owner was also well aware of the temperature of the water because he warns prospective customers in the KayakInstitute brochures that the water gets really cold.... The language of the brochure did not reflect the more emphatic instruction in the kayak owner's manual which warns that the greatest single danger to sea kayakers is hypothermia. Cold water kills. Wear your wetsuit. Learn about hypothermia. Because the woman in the kayak which became separated from group one had heeded the advice of the guide to dress warmly, she increased her chances of survival. Although she developed hypothermia after her kayak capsized, her layered clothing reduced its severity and ensured her survival. The chances of survival of the man who died would have been greater had he been warmly dressed. Prospective charterers were not given sufficient information in the brochure upon which to make an informed decision concerning the wearing of a wet suit. It is probable that neither person would have developed severe hypothermia had the wearing of a wet suit been mandatory during the trip. 2.5 Group Discipline The importance of group discipline on such an excursion was not emphasized by its leaders during training. This had a causal and contributory effect on the crises which developed. Because the charterers did not fully understand the importance of the buddy system, they ignored it. Although the guides tried to impose the buddy system, kayakers formed themselves into the groupings they wished. This resulted in a situation where the head guide, who was preoccupied with rescue efforts, was in charge of eight charterers while the assistant guide was in charge of one. The kayaking industry requires that the voluntary norm for the ratio of guides to charterers be of one to four. This norm which had been respected at the outset of the day's trip was exceeded. It is likely that the head guide did not realize that there were this number of charterers in his group. While the weather was the primary reason the two kayakers became separated from group one, the fact is that the head guide was not in a position to help them because he was already engaged in two rescues. 2.6 Use of Radio Equipment Because of battery life considerations, it was practicable to use the radios only on the hour when the two groups were out of sight of each other. The system failed in that the head guide was heavily occupied in rescue or towing efforts at 1800 and 1900. Had the guides been able to make contact at these times, SAR efforts could have been commenced much earlier than was the case. 2.7 Search and Rescue The reason for the delay in starting up the SAR operation was that the head guide did not realize at first that two kayakers were missing from his group. Because of this, he initially declined the assistance offered to him. Because the assistant guide had expertise in radio communications, the SAR operation was, in the main, successful. In the beginning, the search was scattered because of a lack of hard information and the dispersion of the kayaks. By relaying messages and correcting misunderstandings, the assistant guide was able to clarify the initial confusion. 2.8 Emergency and Safety Equipment The side sponsons and/or paddle floats were not inflated and installed ahead of time to assist the kayaker to reboard after a possible capsizing or to increase the stability of the kayaks. Consequently, when the kayakers entered an area of rough seas, they had to keep paddling to keep their kayaks upright. Each kayak was equipped with these floats. The secondary use of the sponsons, i.e. to increase the stability of the kayaks, was not foreseen before the kayaks encountered severe weather. 2.9 Kayak Design Considerations The capsizing and downflooding of the second kayak are probably attributable to the fact that the U-shaped outer pod seal had been pulled off the coaming probably as the occupant exited the pod when the kayak capsized. It could not be determined if the inner seal was defective because the owner later replaced both seals. These replacements cured the leak but it is unknown which replacement cured the problem. Because pumping arrangements are confined to the pod, there is no arrangement to pump out the hull if it becomes flooded. Removal of water from the hull requires that the kayak be inverted with the watertight deck hatches removed. It was for this reason that the kayak's occupant was rescued and the kayak abandoned. As a result of the back support cushion in another kayak not being secured, the woman using the kayak was unable to reach the foot pedals used to steer the rudder. This lack of control of the kayak caused its occupant to panic, quit the group and contributed to the confusion during the SAR operation. In the circumstances, it was fortuitous that this person was able to make a landing although she was injured in the process. 3.0 Conclusions 3.1 Findings The level of training and practical exercises given to the inexperienced charterers before setting out on the sea voyage was not sufficient to ensure the survival of all the participants when bad weather was encountered. The charter company's brochure did not give prospective charterers sufficient information to make an informed decision concerning the wearing of a wet suit. The voyage was continued after weather forecasts predicted conditions unsuitable for small craft such as kayaks. Stabilizing equipment was not fitted to the kayaks before they entered an area of rough water. The majority of the kayakers were not aware of the head guide's intended stop-over points or of the final destination. No voyage plan was given to a Coast Guard Radio Station (CGRS). Group discipline broke down when the guides did not enforce the buddy system or ensure that the number of kayakers in each group remained manageable. Half of the group did not heed the head guide's advice to dress warmly for the passage. The fact that the deceased was lightly clad probably caused the quick onset of hypothermia. The head guide, preoccupied with rescue efforts, was unaware that four members of his group were missing and initially declined assistance offered by the CGRS Prince Rupert. The assistant guide's expertise in radio communication ensured that a Search and Rescue mission was mounted and, because he relayed messages, initial misunderstandings and confusion were clarified. 3.2 Causes The inexperienced group attempted a sea journey even though they were under-trained to safely handle their craft and to cope with emergencies, and were ill-prepared for the open water conditions which could be expected from the weather forecast. The fact that group discipline was not enforced and that the Search and Rescue mission was delayed because of initial confusion in the group and radio communications difficulties contributed to the death of one member of the group. 4.0 Safety Action 4.1 Action Taken 4.1.1 Charter Vessels As a result of several occurrences, the TSB issued five marine safety recommendations in February 1994 with respect to charter vessels and the circumvention of safety regulations. The Board recommended that: The Department of Transport conduct a formal safety evaluation of the Canadian charter boat industry to include the adequacy of vessel inspection and crew certification requirements as well as current operational practices; The Department of Transport expedite its currently proposed amendment to the Canada Shipping Act with respect to the carriage of the fare-paying public as passengers on charter vessels; The Department of Transport encourage all charter vessel operators to equip their vessels with life-saving and emergency communication and/or signalling equipment suitable for the type of operation; The Department of Transport encourage charter boat operators to establish sailing plans and to conduct passenger safety briefings before getting under way; and The Department of Transport initiate research and development into ways of ensuring the accessibility of all emergency equipment, including in a capsizing situation. 4.1.2 Working Group on Charter Operations Following this occurrence, the Canadian Coast Guard (CCG) established an all-region working group consisting of representatives from CCG offices across the country with a view to produce a policy document on charter vessel operations and safety. 4.1.3 Safety Study on Charter Vessel Operations In response to recommendation M94-01, the CCG engaged the Consulting and Audit Canada Group to conduct a formal safety study, Review of Charter Vessel Safety (RCVS). In June 1995, the consultants interviewed some 15 charter vessel operators, builders, architects, and insurance agencies in the western regions and participated in an all-region CCG working group on charter vessels. It is understood that the first draft of the report was completed in September 1995. 4.1.4 Sail Plan In January 1995, the CCG issued Ship Safety Bulletin (SSB) No. 4/95 entitled Recommended Safety Communications Measures for Small Craft. The bulletin is directed to operators of all small craft including fishing and charter vessels. It covers issues such as Coast Guard Radio Stations sail plans processing and alerting service, cellular telephone marine emergency service, and safety briefings. 4.1.5 Boating Safety In 1994, a federal/provincial joint working group was established to deal with three important areas of responsibility regarding boating safety: vessel licensing; operator proficiency and boating safety programs; and enforcement, waterways policing standards and emergency boater assistance. In 1995, the newly restructured Department of Fisheries and Oceans (DFO) created an Office of Boating Safety (OBS). The OBS provides several services with respect to the safety of the recreational boating community. The OBS has also received funding from the National Search and Rescue Secretariat for the production of a video on Safe Kayaking, due in March 1996.